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Breech presentation of the fetus. Breech presentation of the fetus: how to turn? Planned caesarean section with breech presentation

Breech presentation is the incorrect position of the fetus in the uterus., in which not the head, but the legs or buttocks of the child is facing the entrance to the mother's pelvis. This type of presentation occurs in 3-4% of women in labor. Breech presentation does not affect the course of pregnancy and the health of a woman in any way, but for a child it poses a serious danger.

Why is breech presentation dangerous?

For a favorable course of childbirth, the head of the fetus should be inserted into the pelvis of the first woman, since it is the largest and densest part of the baby's body.

Due to the soft seams of the skull, the head is configured for the birth canal and, as it were, pushes them apart. Therefore, after the head leaves the genital tract of the woman in labor, all other parts of the child's body are born quickly and without any problems. In the case of breech presentation, everything happens the other way around. The pelvic end is born first, and the fetal head comes out last. This is fraught with the development of a number of serious complications in childbirth:

  • Premature discharge of amniotic fluid.
  • Prolapse of the umbilical cord or legs of the child.
  • Weakness of labor activity.
  • Clamping the head of the umbilical cord, which can lead to oxygen starvation of the fetus.
  • Ingestion of amniotic fluid by the child.
  • Extension of the head and tilting of the arms of the child.
  • Injuries of the birth canal of a woman.
  • Injuries to the fetus (possibly damage to the neck, spinal cord, cerebellum, hip joints).

Varieties

The most common pure breech presentation. With it, the baby's legs are bent at the hip joints and located along the body (feet near the head), and the buttocks of the child are inserted into the woman's pelvic ring. This position is considered the most favorable in terms of delivery.

Slightly less likely to diagnose mixed breech presentation, in which the legs are bent at the same time in the hip and knee joints, therefore, at the entrance to the small pelvis of the woman in labor are not only the buttocks, but also the feet of the fetus.

The most rare varieties of breech presentation include complete and incomplete foot, as well as knee presentation. With them, the legs of the child, and not the buttocks, are the first to come out of the birth canal.

In childbirth, one variant of the breech presentation can go into another.

Causes

Up to 32-34 weeks of pregnancy, the fetus can repeatedly change its position in the uterus, because there is a lot of space in it. But after 34 weeks, the child becomes larger, there is no longer enough space for him, so he takes the most comfortable position for himself. If all is well, the baby turns head down and waits for his birth in this position. However, this does not always happen. Factors contributing to the development of breech presentation include:

  • Narrow or abnormal pelvis.
  • Pathologies of the uterus, in which there is little space in it or it has an irregular shape that prevents the child from taking a physiological position. This may be the saddle shape of the organ, scars on the wall of the uterus, the presence of a septum in the uterine cavity.
  • Placenta previa.
  • Polyhydramnios, which gives the fetus the ability to spin back and forth until delivery.
  • Low water and multiple pregnancy. These conditions limit the child's mobility, so he cannot take the most optimal position for childbirth.
  • Weak abdominals and hypotension of the uterus. These factors are most often found in women who have given birth repeatedly.
  • Fetal pathologies - prematurity, congenital anomalies.
  • Short umbilical cord or repeated entanglement of the fetus with the umbilical cord.
  • Heredity.

Diagnostics

An experienced obstetrician-gynecologist can determine in what position the fetus is in the uterus during an external examination of a woman, since the head and buttocks are different to the touch. In addition, an indirect sign of breech presentation is a distinct listening to the fetal heartbeat above the navel of the pregnant woman, and not below, as with head presentation. Another important indication of the abnormal placement of the child in the womb is considered to be too high, inappropriate for the gestational age, standing of the fundus of the uterus.

Information about the presenting part of the fetus can also be obtained by a doctor during a vaginal examination of a woman. well and the most informative method for diagnosing breech presentation is.

Methods for correcting breech presentation

With a breech presentation, there are four options for the development of events:

  • The first is that the baby will roll over by itself, and the birth will take place naturally (this happens even after 37-38 weeks).
  • The second is natural childbirth, complicated by breech presentation.
  • The third is planned or emergency (during childbirth).
  • Fourth - the child will be helped to roll over, and he will be born without surgery.

How can you help the baby? There are two methods:


Breech exercises: contraindications

A set of special gymnastic exercises for a pregnant woman with a breech presentation of the fetus is prescribed by gynecologists after 32 weeks of pregnancy. You can’t start classes on your own, because such gymnastics has contraindications, which include:

  • placenta previa;
  • The threat of premature birth.
  • Scar on the uterus.
  • Preeclampsia.
  • Tumors of the uterus.
  • Severe illness of the mother.
  • Multiple pregnancy.

During the exercises, the wall of the uterus is irritated and reflexively contracts, creating inconvenience for the child, which he tries to get rid of by turning over. Therefore, women should not have any problems with the course of pregnancy, otherwise complications may develop.

Gymnastics technique for breech presentation

There are several such methods:

This, of course, is not the whole list of exercises. There are many such methods. And not without reason they are called methods. It is necessary to choose and deal with only one of them, and not all at once. A set of exercises should be prescribed by a doctor, assessing the tone of the pregnant uterus and the condition of the woman.

Childbirth or caesarean section?

If the baby has not turned over head down, at a period of 38 weeks the woman is sent to the pregnancy pathology department, where she will wait for the birth. This is necessary for medical supervision and the choice of the optimal method of delivery. So that doctors can determine whether a woman can give birth on her own, she is sent for ultrasound, CTG (cardiotocography, which allows you to check the fetal heartbeat) and other studies necessary to assess the readiness of a woman's body for childbirth.

Absolute indications for operative delivery are:

  • The mass of the fetus is more than 3.5 kg (with a breech presentation, this is already a large fetus).
  • Fetal weight less than 2 kg.
  • Narrow pelvis.
  • Chronic fetal hypoxia.
  • Severe condition of the mother.
  • Pregnancy after.
  • Scar on the uterus.
  • Placenta previa.
  • The age of the primipara is more than 30 years.
  • Multiple pregnancy.

In all other situations, childbirth can take place naturally under the control of the equipment and, if the medical team is ready, in case of complications, an emergency cesarean section can be performed.

Birth in breech presentation

Due to the complexity, such childbirth is not accepted by a midwife, but by a doctor. In the first stage of labor, the woman in labor is recommended to lie on her side. In the second period, the doctor provides special obstetric care aimed at maintaining the correct articulation of the fetus (the child's legs should be extended along the body and pressed to the chest - this is the optimal position). From the appearance of the pelvic part of the fetus to the complete birth of the entire body, no more than 5-10 minutes should pass, because due to the clamping of the head of the umbilical cord, the child will suffer from hypoxia. Therefore, in order to speed up the process, medical workers cut the mother's perineum and use special techniques to help the baby be born as quickly as possible.

To provide emergency care to a newborn, qualified specialists must be present in the delivery room - a neonatologist and resuscitator. Subsequently, the condition of such children requires close attention from pediatricians and neuropathologists.

If in childbirth with a breech presentation of the fetus, placental abruption begins, a loop of the umbilical cord falls out, the child's condition worsens, or some other complication occurs, the pregnant woman is given an emergency caesarean section.

Zubkova Olga Sergeevna, medical commentator, epidemiologist

Breech presentation is one of the options for the location of the fetus in the uterus, in which the buttocks and legs of the child are at the bottom, and the head is at the top (the child "sits" on the priest). This position of the fetus in the uterus after 32 weeks of pregnancy is considered pathological, as it can significantly complicate natural childbirth or even make it impossible.

What are the causes of breech presentation?

Is natural childbirth possible with breech presentation?

Natural childbirth with a breech presentation is certainly possible, however, it is associated with a greater risk to the fetus. The thing is that during childbirth in a breech presentation, the baby's head leaves the uterus last, and the birth of the head is the most difficult process in childbirth. In this regard, doctors often have to resort to the use of obstetric forceps, which capture the head of the child, which is unsafe for the baby.

Planned caesarean section with breech presentation

Birth by cesarean section in breech presentation is the safest choice recommended by experts around the world. Although a caesarean section is a major operation and carries some risks for the mother-to-be, the risks of vaginal delivery with a breech presentation are generally slightly higher.

Most often, a planned caesarean section with a breech presentation is performed for a period not earlier than 39 weeks. The day before or on the day of the operation, you will have an ultrasound scan to make sure that the fetus has not rolled over into a cephalic presentation.

Features of children born in breech presentation

As a rule, children born in a breech presentation are no different from others. However, neonatologists usually pay more attention to these newborns in order to exclude some complications associated with breech presentation: hip dysplasia, congenital torticollis, swelling of the labia in girls or scrotum in boys, etc.

- longitudinal location of the fetus in the uterus with the legs or buttocks facing the entrance to the small pelvis. Pregnancy with a breech presentation of the fetus often occurs in conditions of threatened abortion, preeclampsia, placental insufficiency, fetal hypoxia, and birth injuries. Diagnosis of breech presentation of the fetus is made using external and vaginal examination, echography, dopplerography, CTG. Treatment of breech presentation includes complexes of corrective gymnastics, prophylactic external rotation of the fetus, early choice of the method of delivery.

General information

Breech presentation of the fetus in obstetrics and gynecology occurs in 3-5% of all pregnancies. The management of pregnancy and childbirth with a breech presentation of the fetus requires qualified and highly professional assistance to a woman and a child. With a breech presentation of the fetus during childbirth, the buttocks or legs of the child are the first to pass through the birth canal. At the same time, the cervix is ​​still in an insufficiently smoothed and open state, so the advancement of the head, as the largest and densest part of the fetus, is difficult. With a breech presentation, childbirth can proceed uncomplicated, but there is an increased risk of asphyxia, stillbirth of the fetus, birth injuries of the child and mother.

Classification of pelvic presentation of the fetus

Variants of the breech presentation of the fetus include foot and breech presentations. The share of foot presentations accounts for 11-13% of cases of all pelvic presentations of the fetus. Foot presentation can be full (both legs), incomplete (one leg) or knee (knees of the fetus). Breech presentations are the most common. In 63-75% of cases, an incomplete (purely gluteal) presentation is diagnosed, in which only the buttocks are adjacent to the entrance to the small pelvis, and the legs of the fetus are extended along the body. With a mixed breech presentation (20-24%), not only the buttocks, but also the legs of the fetus, bent at the knee or hip joints, face the entrance to the small pelvis.

With different variants of the breech presentation of the fetus, the development of the biomechanism of childbirth has its own characteristics. With a purely breech presentation, a medium-sized fetus and the normal size of the mother's pelvis, uncomplicated independent childbirth is possible. With foot and mixed presentation, vaginal delivery is associated with significant risks for the newborn - asphyxia, prolapse of the umbilical cord and certain parts of the fetus.

Causes of pelvic presentation of the fetus

The factors that cause breech presentation of the fetus are numerous and not fully understood. The presence of uterine fibroids, ovarian tumors, anatomical narrowing or irregular shape of the pelvis, anomalies in the structure of the uterus (intrauterine septum, hypoplasia, bicornuate or saddle uterus) can prevent the head from being established at the entrance to the small pelvis.

Breech presentation can be observed with increased fetal mobility caused by polyhydramnios, malnutrition or prematurity, hypoxia, microcephaly, anencephaly, hydrocephalus and other factors associated with the pathology of the child. On the other hand, the limited mobility of the fetus in the uterine cavity with oligohydramnios, a short umbilical cord or its entanglement also contributes to the formation of an malpresentation.

An obstetric and gynecological history of the mother, aggravated by repeated curettage of the uterus, endometritis, cervicitis, multiple pregnancies, abortions, complicated childbirth, can lead to pelvic presentation of the fetus. These conditions often lead to the development of pathological hypertonicity of the lower segments of the uterus, in which the head tends to take a position in the upper, less spasmodic sections of the uterine cavity. A change in the tone of the myometrium can also be caused by a scar on the uterus, neurocirculatory dystonia, neurosis, overwork of the pregnant woman, stress, etc. Pelvic presentation of the fetus is often combined with a low location or placenta previa.

In numerous observations conducted by obstetrics and gynecology, it is noted that the breech presentation of the fetus develops in those women who themselves were born in a similar situation, therefore, the issue of hereditary conditioning of foot and gluteal presentations is being considered.

Features of the course of pregnancy

With a breech presentation of the fetus, the course of pregnancy, much more often than with a head one, is associated with a threat or spontaneous interruption, the development of preeclampsia and placental insufficiency. These conditions, in turn, negatively affect the maturation of the nervous, endocrine and other systems of the fetus. With breech presentation in the fetus from 33-36 weeks of gestation, the processes of maturation of the structures of the medulla oblongata slow down, which is accompanied by pericellular and perivascular edema. At the same time, the neurosecretory cells of the fetal pituitary gland begin to work with increased activity, leading to premature depletion of the function of the adrenal cortex, and a decrease in the protective and adaptive reactions of the fetus.

Changes in the fetal gonads are represented by hemodynamic disorders (venous stasis, punctate hemorrhages, tissue edema), which can later manifest as gonadal pathology - hypogonadism, ovarian wasting syndrome, oligo- or azoospermia, etc. With breech presentation, the incidence of congenital malformations increases heart, central nervous system, gastrointestinal tract, musculoskeletal system in the fetus. Violations of the uteroplacental blood flow are manifested by hypoxia, high heart rate, and a decrease in fetal motor activity. During childbirth with a breech presentation of the fetus, discoordinated or weak labor activity often develops. The most gross changes are observed in cases of mixed breech or foot presentation.

Diagnosis of pelvic presentation of the fetus

A stable breech presentation of the fetus should be discussed after the 34th-35th week of gestation. Until this time, the location of the presenting part may be variable. The breech presentation of the fetus is determined through external obstetric and vaginal examinations.

The breech presentation of the fetus is characterized by a higher standing of the uterine fundus, which does not correspond to the gestational age. Methods of external research make it possible to determine in the area of ​​the womb a soft, irregularly shaped, inactive part of the fetus that is not capable of balloting. In the region of the fundus of the uterus, on the contrary, it is possible to palpate a large, rounded, hard and mobile part - the head of the fetus. The heartbeat is heard above or at the level of the navel.

Management of pregnancy and childbirth

In patients belonging to high-risk groups for the formation of breech presentation, during pregnancy, measures are taken to prevent fetoplacental insufficiency, disorders of uterine contractile activity, and fetal complications. A pregnant woman is recommended to observe a sparing regimen with a full night's sleep and daytime rest, a balanced diet to prevent fetal hypertrophy.

Psychoprophylactic work is carried out with pregnant women, aimed at teaching the methods of muscle relaxation and relieving nervous excitability. From the 35th week of gestation, corrective gymnastics is prescribed according to Dikan, Grishchenko and Shuleshova, Caio, which contributes to a change in the tone of the myometrium and abdominal wall muscles, and the transfer of the fetus from pelvic presentation to head presentation. In some cases, spasmolytic drugs are prescribed in intermittent courses.

Conducting an external prophylactic rotation of the fetus on the head according to Arkhangelsk in some cases turns out to be ineffective and even dangerous. The risks of such an obstetric appointment can be the onset of premature placental abruption, rupture of the membranes, premature birth, uterine rupture, trauma and acute fetal hypoxia. These circumstances in recent years have limited the use of external obstetric aids in the practice of treating breech presentations of the fetus.

A pregnant woman with a breech presentation of the fetus at the 38-39th week of gestation is hospitalized in an obstetric hospital for planning the tactics of childbirth. In an uncomplicated obstetric situation (satisfactory condition of the fetus and the woman in labor, the proportionality of the pelvis and fetus, the biological readiness of the maternal organism, purely breech presentation, etc.), childbirth through the natural birth canal is possible. At the same time, prevention of premature opening of the fetal bladder, constant monitor CTG control of the fetus and uterine contractions, and drug prevention of labor anomalies are carried out.

In children born in breech presentation, often determined intracranial injury, encephalopathy, spinal injury, hip dysplasia. If fetal asphyxia or amniotic fluid aspiration is detected, appropriate resuscitation measures are required. Newborns in the early neonatal period are subject to a thorough examination by a neurologist. Typical for breech presentation of the fetus, birth injuries in women include perineal ruptures, cervix, vagina and vulva, and damage to the pelvic bones.

The preventive direction provides for a thorough examination and correction of disorders in women planning a pregnancy; identification of pregnant risk groups for the development of breech presentation of the fetus and timely and adequate preparation for childbirth; early choice of tactics of childbirth and their conduct under continuous control

Breech presentation, what is this phenomenon, what is dangerous for natural childbirth, and what problems can a woman and a child have in connection with this? Perhaps this article should begin with a reminder that in most cases, and this is the absolute norm, the child is located in the uterus upside down. This position is firmly occupied by the child after the 30th week of pregnancy, before this period the baby often changes position, since it is still relatively small and there is enough space in the uterus. The problem may be the breech presentation of the fetus later than 30-32 weeks, since at this time the fetus is quite large and there is much less chance that it will unfold “as it should”, that is, head down. After all, the child in the breech presentation was not accidental, it is more convenient for him. But there are ways to "force" the baby to drop head down - these are special exercises. We will describe them below. But first, let's find out what are the reasons for the location of the child's head up in the uterus.

Breech presentation has a variety of reasons. The risk of this feature increases in women who have given birth multiple times, due to stretching of the walls of the uterus and a decrease in their tone; with polyhydramnios due to too much space for the movements of the child; with uterine fibroids, a narrow pelvis, a short umbilical cord, etc. Unfortunately, when pregnancy occurs, breech presentation can hardly be prevented with the help of some preventive measures. Unless a bandage for pregnant women, which is recommended to be worn from the 16th week of pregnancy, can help.

Correcting the situation

What to do if the child is in the wrong position? If the period is more than 30 weeks, it is necessary to perform special exercises for breech presentation - there are only three main ones.

You need to lie on your back, bend your knees and raise your pelvis (you can just put it on a pillow) by about 30-40 cm. It is important that a straight line looms from your shoulders to your knees. Often, this exercise alone, performed once, is enough to turn the child over.

Another, more active variation of the same exercise. A pillow is not needed. The starting position is the same, but the pelvis is on the floor. On inspiration, it must be raised, while leaning on the shoulders and feet. On exhalation, the pelvis descends.

The third exercise is very calm, it can be done while watching TV or before going to bed. You need to lie on one side for 10 minutes, then roll over your back to the other side, lie on it for 10 minutes. Repeat for 30-40 minutes.

delivery

When the position of the fetus is longitudinal presentation, pelvic delivery is possible in a natural way. But the management of childbirth has its own characteristics, so you need to trust only a very experienced obstetrician-gynecologist.

Childbirth with a breech presentation often begins with the discharge of amniotic fluid, and not contractions. The duration of the fights can be long. It is very important to correctly conduct the second stage of childbirth, that is, to correctly accept the child. When a baby is born with a head, everything is simpler, it immediately expands the birth canal. When the baby walks with the buttocks or legs, it is more difficult for the head to be born. And a common dangerous complication of this is birth trauma, as well as squeezing of the umbilical cord, which leads to acute hypoxia, and if the doctor hesitates, then to the death of the child.

During its development, the baby, which is in the mother's tummy, rolls over several times. And after 22-23 weeks of pregnancy, the baby, as a rule, assumes a head-down position - and this is the location of the fetus that is considered optimal for subsequent births. The head of the fetus is the largest part of its body in diameter, and therefore it is with its passage during delivery that the greatest difficulties are associated. After the baby's head passes through the birth canal, the rest of his body "by inertia" follows almost imperceptibly. If the baby is located vertically in the mother's tummy, that is, head down, in most cases this position does not bring any difficulties. But it also happens that the fetus occupies a transverse position in the womb: legs or buttocks down. In this case, we are talking about breech presentation during pregnancy, which is diagnosed, as a rule, by the 28th week during the next visit to the antenatal clinic. It should also be mentioned that the breech presentation detected at this time will not necessarily remain until the birth - the baby can change position up to 36 weeks. In addition, there are a number of measures that can help "turn" the fetus, thereby giving it a head position.

Causes of breech presentation of the fetus

Breech presentation of the fetus during pregnancy can be due to several factors. One of the main reasons doctors call a decrease in the tone and excitability of the uterus. Also, the causes of breech presentation are called, and abnormalities in the development of the uterus, placenta previa, some malformations of the fetus. Breech presentation can be breech, foot, mixed, knee - each of them is easily diagnosed by the doctor during a routine examination, after which ultrasound confirmation will be necessary. Breech presentation is considered not quite a normal position for both the baby and the mother - although it does not carry direct big threats.

Although natural childbirth with a breech presentation of the fetus is possible, caesarean section often becomes an indication for delivery. If the birth proceeds in a natural way, constant and enhanced monitoring by the doctor is necessary - childbirth from a breech presentation is much more often accompanied by complications.

Signs of breech presentation of the fetus

Physically, if there is a breech presentation of the fetus, the woman does not feel this pathology in any way. She is not disturbed by any pain symptoms or discomfort, which can clearly signal the "wrong" location of the baby in the uterus.

Breech presentation can only be determined through examinations. So, with breech presentation, experts note a higher standing of the uterine fundus above the pubis, which does not correspond to the gestational age. The fetal heartbeat is heard more clearly in the umbilical region or slightly above it on the right or left (depending on the position of the fetus).

Also, signs of breech presentation of the fetus reveal themselves during a vaginal examination. For example, with a breech presentation, a soft volumetric part, inguinal fold, coccyx and sacrum are probed. With adjacent breech and foot presentation, you can determine the baby's feet with a calcaneal tubercle and short fingers (other than fingers on the hands) located on the same line. To clarify the diagnosis, however, ultrasound will also be required.

Exercises for breech presentation of the fetus

You can “give” the baby a head position in the tummy with the help of special gymnastic exercises. You can use them starting from 32-34 weeks of pregnancy - after consultation with your doctor. Gymnastic exercises involve turning the future mother in a prone position from one side to the other: 3-4 times approximately every 7-10 minutes. This exercise is performed 2-3 times a day. You can also carry out an exercise that involves lifting the pelvis: lying on your back, you should put some kind of roller under your lower back (you can use ordinary pillows) so that the pelvis is 20-30 centimeters higher than the head. In this position, you need to stay from 5 to 15 minutes, but no more. The exercise is performed 2-3 times a day on an empty stomach. Contraindications for performing such gymnastics are scars on the uterus from any operations, late toxicosis. He offers his methods for breech presentation and alternative medicine, for example, acupuncture, homeopathy,.

If the above methods have not brought the desired results, the expectant mother may be offered an external rotation of the fetus. This procedure is carried out at about 34-37 weeks of pregnancy, always in a hospital with monitoring, ultrasound monitoring and using special preparations that relax the uterus. A successful external coup will make it possible later to carry out childbirth in a natural way, but since this procedure is rather difficult, and also has many contraindications (a scar on the uterus, obesity, the age of the primipara is more than 30 years old, preeclampsia,), it is not suitable for every pregnant woman and they produce it quite rare.

Childbirth with breech presentation of the fetus

If the breech presentation could not be eliminated by any of the methods, this should not become a reason for the disorder. In this case, the pregnant woman will be advised to go to the obstetric hospital earlier: here, after all the necessary examinations, the method of delivery will be chosen.

Without any serious contraindications, childbirth can proceed naturally - under the constant supervision of a doctor. If it is not possible, a caesarean section will be required. Indications for cesarean section with breech presentation are (more than 3.5 kilograms), the presence of a scar on the uterus, a narrow pelvis in a pregnant woman, placenta previa, presentation in a foot or mixed position.

Specially for- Tatyana Argamakova